OPTHALMIC RECORD

Tutor:
DR. dr. Gilbert W.S. Simanjuntak, Sp.M (K)

Examiner:
Arawinda Haniastri
1061050069

DEPARTMENT OF OPHTHALMOLOGIC
FACULTY OF MEDICINE
PERIOD: AUGUST 31th, 2015 OCTOBER 3rd, 2015
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA 2015

OPHTHALMIC RECORD
Name of Examiner

: Arawinda Haniastri

NIM

: 1061050069

Date of examination

: September , 2015

Tutor

: DR. dr Gilbert W.S. Simanjuntak SpM (K)

PATIENT IDENTITY

I.

Name

: Mr. S

Age

: 53 years old

Address

: Jl. Sabirin, Kota baru, Jogja

Occupation

: Pension

Religion

: Islamic

Education

: Graduated senior high school

Status

: Marriage

ANAMNESIS (September 9th , 2015)

Main complaint
Blurry vision in left eye
Additional complaint
Red, painful, swollen, and like seeing a rainbow when seeing the light in the
left eye. Vomite and headache.
History of disease
Patient came to YAP Hospital with main complaint blurry vision in his left eye
since 1 day ago for long and near vision. Complaints arise suddenly, ongoing,
and felt increasingly heavy. Patient complains could only see vague shadows.
In addition, patients also see the colors of the rainbow if it sees the light, red
left eye, pain in the left eye and swelling. Patients also complain of nausea and
vomiting when the pain in the left eye and headaches appear. Patients taking
Panadol and lying down to reduce complaints, but complaints resurfaced.
Patients not using glasses before. Itching of the eyes denied, denied excess dirt
eyes, there is something like a sand wedge denied and denied fever.

Previous disease
The patient said that he never had this situation before.
The presence of diabetes or high blood pressure is denied.
History of physical trauma, history of using long-term drug, allergies
and history of contact lenses used are denied.
Family disease history

There is nobody in his family who experience the complaints like him
The presence of diabetes or high blood pressure is denied.

Personal habit

The patient denied the using of lens contact, smoke, and consume
alcohol

II.

GENERAL STATUS
General condition

: moderate appearance of illness

Symptom or illness related to the complaint : None

III.

OPHTHALMIC STATUS
A. General Examination
Periocular appearance

Right Eye
Quiet

Left Eye
Quiet

General condition of the eye

Normal

Unwell

Eyeball position

Symmetric

Symmetric

Eyeball movement

Normal

Normal

Visual field

Same
examiner

with Narrower
examiner

B. Systematic Examination
Right Eye

Left Eye

than

Visual acuity
Before correction
Correction
Super cilia
Cilia
Margo
superior

Palpebra

Margo
inferior

Palpebra

Tarsal
superior

conjunctiva

Tarsal
inferior

conjuntiva

Bulbar conjunctiva

Cornea
Anterior chamber
Iris
Pupil

Lens
Eye ball
Palpation
Tonometry schiotz
IV.

6/6
Normal,
Madarosis (-)

1/300
can not be corrected
Normal,
Madarosis (-)

Normal,
Madarosis (-), Trichiasis (-)

Normal,
Madarosis (-), Trichiasis (-)

Edema (-), tenderness (-),

ectropion (-), entropion (-),
ulcus (-), crusting (-)
Edema (-), tenderness (-),
ectropion (-), entropion (-),
ulcus (-), crusting (-)
Hyperemic (-), Papilar (-),
Follicle (-), Bleeding (-)

Edema(-),tenderness (-),
ectropion (-), entropion (-),
ulcus (-), crusting(-)
Edema(-), tenderness(-),
ectropion (-), entropion (-),
ulcus (-), crusting (-)
Hyperemic (-), Papilar (-),
Follicle (-), Bleeding (-)

Hyperemic (-), Papilar (-),

Follicle (-), Bleeding (-)

Hyperemic (-), Papilar (-),

Follicle (-), Bleeding (-)

Conjunctiva injection (-),

conjunctiva ciliar (+)
pinguekula (-), pterigium (-),
secretion (-)
Clear
Infiltrate (-) Ulcus (-)
Arch senile (-)
Deep,
hypopion (-), hyphema(-)

Conjunctiva injection(+),
conjunctiva ciliar (+)
pinguekula (-), pterigium (-),
secretion (-)
Turbid
Infiltrat (-) Ulkus (-)
Arch senile (-)
Shallow,
hypopion (-),hyphema(-)

Radier
Colour : Brown
Sinekia (-)
Round, anisochor
3mm
Direct light reflexs (+)
Non direct light reflex (+)
Clear
Shadow test (-)

Radier
Colour : Brown
Sinekia (-)
Round, anisochor
5mm
Direct light reflexs (-)
Non direct light reflex (-)
Clear
Shadow test (-)

Normal

N+2

19 mmHg

65 mmHg

RESUME
Patient came to YAP Hospital with main complaint blurry vision in his
left eye since 1 day ago for long and near vision. Complaints arise suddenly,

ongoing, and felt increasingly heavy. Patient complains could only see vague
shadows. In addition, patients also see the colors of the rainbow if it sees the
light, red left eye, pain in the left eye and swelling. Patients also complain of
nausea and vomiting when the pain in the left eye and headaches appear.
Patients taking Panadol and lying down to reduce complaints, but complaints
resurfaced. Patients not using glasses before. Itching of the eyes denied,
denied excess dirt eyes, there is something like a sand wedge denied and
denied fever.The patient said that he never had this situation before. The
presence of diabetes or high blood pressure is denied. History of physical
trauma, history of using long-term drug, allergies and history of contact lenses
used are denied. There is nobody in his family who experience the complaints
like him.
Ophthalmic Examination
Right Eye

Left Eye

Normal

Unwell

Same with examiner

Narrower than examiner

6/6
Normal

1/300
Can not be corrected
Normal

Tarsal conjunctiva
superior

Normal

Normal

Bulbar conjunctiva

Normal

Conjunctiva injection(+),
conjunctiva ciliar (+)

Clear

Shallow

Deep,
hypopion (-), hyphema(-)

Turbid,
hypopion (-),hyphema(-)

Radier
Sinekia (-)

Radier
Sinekia (-)

General condition
of the eye
Visual field
Visual acuity
Before correction
Correction
Margo
Palpebra
superior

Cornea
Anterior Chamber
Iris

Pupil

Lens

Round, anisochor
3mm
Direct light reflexs (+)
Non direct light reflex (+)
Clear

Round, anisochor
5mm
Direct light reflexs (-)
Non direct light reflex (-)
Clear

Normal

N+2

19 mmHg

65 mmHg

Eye ball
Palpation
Tonometry schiotz

V.

CLINICAL DIAGNOSE

Right Eye

Left Eye
Glaucoma acute

VI.

DIFFERENTIAL DIAGNOSE

Right Eye

Left Eye
Keratitis acute OS
Iritis OS

VII.

TREATMENT
Medication :

Pilokarpin 2% eyedrop 4x1 drops a day OS

Acetazolamide tablet 250 mg 2x1 tablet a day

Operative :

Iridectomy

VIII. SPECIFIC EXAMINATION

IX.

Slit lamp
Perimetry
Gonioscopy
Funduscopy

PROGNOSIS

Ad vitam
Ad sanationum
Ad functionum

Right Eye

Left Eye

Bonam
Bonam
Bonam

Bonam
Dubia ad malam
Dubia ad malam

MEDICAL

X.

COMPLICATIONS
Glaucoma absolut OS